Knee Pain/OA Physical Therapy Approaches

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1 Knee Pain/OA Physical Therapy Approaches G. Kelley Fitzgerald, PT, PhD, FAPTA Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences Director, Physical Therapy Clinical and Translational Research Center

2 Dosage Manual Therapy Motor Learning

3 Strength Training Dosage % of a repetition maximum Perceived Exertion Scales For our patients with arthritis, these should be pain-free entities

4 Strength Training Dosage American College of Sports Medicine Recommendations for Older Adults 60-80% 1 RM, 8-12 reps, 1-3 sets, with 1-3 min rest between sets. Can also incorporate power programs of 30-60% 1 RM, 6-10 reps, 1-3 sets at higher repetition velocity. For endurance training, use lighter loads (50-60%) with higher reps (10-15 or more)

5 Progression of Strength Training Intensity When patient can perform 1-2 reps over the target reps for 2 consecutive sessions, training load should be increased by 2 to 10%. Recommend re-establishing the 1 RM every 2 to 4 weeks to re-adjust training loads appropriately.

6 Alternative to Repetition Maximum for Dosing Modified Borg Perceived Exertion Scale Borg Perceived Exertion Scale 0 Nothing at all 1 Very light 2 Fairly light 3 Moderate 4 Somewhat Hard 5 Hard 6 7 Very Hard Very very hard Borg, G. (1982) Psychophysical bases of perceived exertion. Medicine and Science in Sports and Exercise, 14 (5), p

7 Alternative to Repetition Emphasize gains in muscle force output Maximum for Dosing Increase resistance as patient progresses and RPE falls below desired level. Borg Perceived Exertion Scale 0 Nothing at all 1 Very light 2 Fairly light 3 Moderate 4 Somewhat Hard 5 Hard 6 7 Very Hard Very very hard

8 Alternative to Repetition Emphasize gains in endurance Maximum for Dosing Increase resistance as patient progresses and RPE falls below desired level. Borg Perceived Exertion Scale 0 Nothing at all 1 Very light 2 Fairly light 3 Moderate 4 Somewhat Hard 5 Hard 6 7 Very Hard Very very hard

9 Alternative to Repetition Maximum for Dosing Potential Advantages of RPE Can dose without need for major testing equipment Easy to teach patient for independent exercise and activity programs Potential Disadvantages of RPE Not yet known if it will produce the same strength outcomes as %RM approach

10 Aerobic Training Dose 30 to 60 minutes per week 50-70% of heart rate reserve (HRR) Target HR = 220- Age (Resting HR x %HRR) + Resting HR Example: 60 y/o with resting HR of 80, exercise at 60% of HRR: (80 X.60) + 80 =128 beats/min

11 Manual Therapy Techniques include accessory and physiologic motion techniques, manual stretching techniques, and soft tissue manipulation techniques

12 Examples of Manual Therapy Techniques Manually applied stretch to the hamstrings and posterior capsule P-A glide of tibia on femur with medial tibial rotation: Target anterior-lateral capsule

13 Examples of Manual Therapy Techniques Accessory Motion: Patellofemoral inferior glides Soft tissue manipulation with manual stretching

14 Manual Therapy: Joint Mobilization Can be used to induce relaxation and reduce pain (grades 1 and 2) Can be used to improve joint mobility (grades 3-5) Objective of treatment is to manually reproduce joint accessory motions such as distractions and joint surface translations. Can also be used to apply more targeted stretching of joint capsule Moss P, et al, Manual Therapy. 2007;12: Deyle G, et al, Phys Ther. 2005;85:

15 Joint Mobilization: Indications Hypomobility on accessory motion testing (reproduction of joint translatory movements) Measureable reduction in joint motion even after de-emphasizing contribution from tight muscles Pain/stiffness in specific portions of the peri-articular soft tissue on joint motion

16 Deyle, et al. Phys Ther. 2005; 85: Compared group with knee OA receiving supervised manual therapy and exercise to group receiving home exercise. Manual therapy and exercise delivered to lumbo-pelvic, hip, knee, foot and ankle regions based on reduced motion or pain in these regions.

17 Deyle, et al. Phys Ther. 2005; 85: Both groups improved function scores. Group receiving supervised manual therapy and ex had greater improvements. (52% vs 26%) Larger effect compared with many other exercise studies.

18 Abbott JH, et al. Osteoarthritis Cartilage. 2013;21: Usual Care (UC) N = 51 UC + Exercise (Ex) N = 51 UC + Manual Therapy (MT) N =54 UC+MT+Ex N = 50 Included subjects with knee or hip OA 9 sessions (7 in first 9weeks +2 boosters at 16 weeks)

19 Abbott JH, et al. Osteoarthritis Cartilage. 2013;21: WOMAC (51.8) 30s sit to stand (# stands) ONE YEAR FOLLOW-UP CHANGES UC MT Ex MT + Ex.02 (-.79;.84) 40m walk (sec).78 (-1.40;2.95) (55.5).67 (-.12;1.45) -.50 (-3.70;2.70) (50.4) 1.6 (.80;2.40) (-4.41; -1.99) (41.1) 1.59 (.60;2.59) -.61 (-2.22; 1.00) NNT* * Number needed to treat for achieving responder to treatment status based on OMERACT-OARSI responder criteria

20 Enhancing the Effectiveness of Physical Therapy in People with Knee Osteoarthritis 1 RO1 HS University of Pittsburgh, Pittsburgh PA- Data Coordinating Center (PI: G. Kelley Fitzgerald) Other Study Sites: University of Utah/Intermountain Healthcare, Salt Lake City, UT (PI: Julie M. Fritz) Army-Baylor University, San Antonio, TX (PI: John Childs) University of Otago, Dunedin NZ (PI: Haxby Abbott)

21 Summary of Experimental Design Baseline Testing R Exercise MT +Exercise Exercise +Booster MT+ Exercise +Booster 12 Rx Sessions 12 Rx Sessions 8 Rx Sessions 8 Rx Sessions 9 Wk F/U 9 Wk F/U 9 Wk F/U 9 Wk F/U Home Program Home Program Home Program Home Program 5 mo Booster 2Rx 5 mo Booster 2Rx 8 mo Booster 1Rx 8 mo Booster 1Rx 11 mo Booster 1Rx 11 mo Booster 1Rx 1 YR F/U 1 YR F/U 2 YR F/U 2 YR F/U 1 YR F/U 1 YR F/U 2 YR F/U 2 YR F/U

22 Motor Learning Approaches Biomechanical unloading Task Specific Training

23 Contralateral Cane Use KAM by 7-10% cumulative loading by: stride length cadence GRF by 25%-35% during gait Most effective if placed as far laterally as possible without inducing sx.

24 Gait Retraining Approaches Goal to reduce knee adduction moment Foot progression angle (toe out) Trunk sway (lateral)

25 Motion capture and instrumented treadmill Patient tailored altered foot progression angle or lateral trunk to get 10% in KAM Vibration motors on tibia (foot angle) and scapula (trunk sway) for feedback during training Shull PB, et al. J Orthop Res. 2013;31:

26 1x/week, 6 weeks 10 min practice daily Subject selected method of alteration Foot progression angle Trunk sway Both Fading feedback training design Shull PB, et al. J Orthop Res. 2013;31:

27 Shull PB, et al. J Orthop Res. 2013;31: Department of Physical Therapy

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29

30

31 Task-Specific Training

32 Traditional Premise Physical Function + Performance

33 Traditional Premise Physical Function + Performance

34 Changes in impairments (muscle strength, flexibility, joint mobility) not associated with clinical outcome of pain and function in subjects with knee OA. Fitzgerald GK, White DK, Piva SR. Associations for change in physical and psychological factors and treatment response following exercise in knee osteoarthritis: An exploratory study. Arthritis Care Res. 2012;64:

35 Impairment-based rehabilitation approach yielded only modest selfreported improvements in functional task performance ability Teixeira PEP, Piva SR, Fitzgerald GK. Effect of impairment-based exercise on performance of specific selfreported functional tasks in individuals with knee osteoarthritis. Phys Ther. 2011;91:

36 Task-Specific Training Use the specific task that is problematic as the training tool Can work on strength and joint mobility in context of the task Provide opportunity to improve motor patterns in context of task May consider task modifications

37 Chair Rise Task Step 1: Moving to Edge of Seat

38 Chair Rise Task Step 2: Lift Off

39 Chair Rise Task Step 3: Terminal Stand Department of Physical Therapy

40 Chair Rise Task Full Task Practice Department of Physical Therapy

41 Floor Transfers Department of Physical Therapy

42 THANK YOU!!!

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